Va Form 10-2850a - Application For Nurses And Nurse Anesthetists
Download a blank fillable Va Form 10-2850a - Application For Nurses And Nurse Anesthetists in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 10-2850a - Application For Nurses And Nurse Anesthetists with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Approved Exception To SF 171
OMB No. 2900-0205
Use TAB key or Mouse to move between data fields
Estimated burden: 30 minutes
Expiration Date: 3/31/2006
APPLICATION FOR NURSES AND NURSE ANESTHETISTS
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER.
INSTRUCTIONS: Please submit this application furnishing all information in sufficient detail to enable the Department of Veterans
Affairs to determine your eligibility for appointment in Veterans Health Administration. Type, or print in ink. If additional space is
required, please attach a separate sheet and refer to items being answered by number.
1. NAME (Last, First, Middle)
2. APPLICATION FOR (Check one)
GENERAL PRACTICE
SPECIALTY (Identify Below)
3. PRESENT ADDRESS (Street Address 1)
STREET ADDRESS 2
APT. NO.
4. TELEPHONE NUMBER (Include Area Code)
4A. RESIDENCE
4B. BUSINESS
CITY
STATE
ZIP CODE
COUNTRY
5. DATE OF BIRTH
6. PLACE OF BIRTH
STATE
COUNTRY
7. SOCIAL SECURITY NUMBER
8A. CITIZENSHIP
8B. COUNTRY OF WHICH YOU ARE A CITIZEN
U.S. CITIZEN BY BIRTH
NATURALIZED U.S. CITIZEN
NOT A U.S. CITIZEN (Complete item 8B)
9A. HAVE YOU EVER FILED APPLICATION FOR APPOINTMENT IN THE VA
9B. NAME OF OFFICE WHERE FILED
9C. DATE FILED
YES
NO
(If "YES" complete items 9B and 9C)
10. WHEN MAY INQUIRY BE MADE OF YOUR PRESENT EMPLOYER
11. DATE AVAILABLE FOR EMPLOYMENT
I - ACTIVE MILITARY DUTY
12A. DATE FROM
12B. DATE TO
12C. SERIAL OR SERVICE NO. 12D. BRANCH OF SERVICE
12E. TYPE OF DISCHARGE
HONORABLE
Other (Explain on seperate sheet)
II - REGISTRATION AND CLINICAL PRIVILEGES
13A. LIST ALL STATES/TERRITORIES IN WHICH YOU ARE NOW OR HAVE
13B. REGISTRATION NUMBER
13C. EXPIRATION DATE
EVER BEEN REGISTERED AS A NURSE (If necessary, continue on separate sheet)
15. DO YOU HAVE PENDING OR HAVE YOU EVER
16. HAVE YOU EVER HELD A REGISTRATION TO
14. ARE YOU FULLY REGISTERED IN EVERY
HAD ANY REGISTRATION TO PRACTICE REVOKED,
PRACTICE THAT IS NO LONGER HELD OR
STATE IN WHICH YOU ARE NOW REGISTERED
SUSPENDED, DENIED, RESTRICTED, LIMITED, OR
CURRENT
(If restricted, limited or probational
ISSUED/PLACED ON A PROBATIONAL STATUS OR
VOLUNTARILY RELINQUISHED
in any State(s), explain on
YES
NO
separate sheet)
YES
NO
(If "YES" explain on separate sheet)
YES
NO
(If "YES" explain on seperate sheet)
17A. DO YOU CURRENTLY HAVE OR HAVE YOU
17B. NAME OF CURRENT OR MOST RECENT
17C. HAVE ANY OF YOUR STAFF
INSTITUTION, AGENCY OR ORGANIZATION WHERE
APPOINTMENTS OR CLINICAL PRIVILEGES
EVER HAD CLINICAL PRIVILEGES AT ANY HEALTH
HELD
EVER BEEN DENIED, REVOKED, SUSPENDED,
CARE INSTITUTION, AGENCY OR ORGANIZATION
REDUCED, LIMITED, OR VOLUNTARILY
RELINQUISHED
YES
NO
(If "YES" explain on separate sheet)
YES
NO
(If "YES" explain on separate sheet)
III - NURSE ANESTHETIST CERTIFICATION (To be completed by Nurse Anesthetists only)
18A. ARE YOU CERTIFIED AS A
18D. HAS YOUR CCNA
18B. WHAT IS THE DATE OF YOUR
18C. WHAT IS YOUR AMERICAN ASSOCIATION
NURSE ANESTHETIST BY THE
CERTIFICATION EVER BEEN
OF NURSE ANESTHETISTS (AANA)
CERTIFICATION OR MOST RECENT
COUNCIL ON CERTIFICATION
REVOKED
IDENTIFICATION NUMBER
RECERTIFICATION (GIVE MONTH AND
OF NURSE ANESTHETISTS (CCNA)
YEAR)
(If "YES" explain
YES
NO
YES
NO
on separate sheet)
IV - THIS SECTION TO BE COMPLETED BY FACILITY DIRECTOR OR DESIGNEE
I certify that I have verified registration with State boards, and sighted visa or evidence of citizenship. Board
CERTIFICATION:
certification has been verified (if appropriate).
19. EVIDENCE HAS BEEN SIGHTED IN REGARDS TO:
CERTIFICATION AS A NURSE ANESTHETIST
VISA
REGISTRATION FOR ALL STATES LISTED BY APPLICANT
NATURALIZED CITIZENSHIP
CURRENT OR MOST RECENT CLINICAL PRIVILEGES
NO CURRENT OR PREVIOUS CLINICAL PRIVILEGES
20A. SIGNATURE OF FACILITY DIRECTOR OR DESIGNEE
20B. TITLE
20C. DATE
VA FORM
PAGE 1
10-2850a
SEP 1998 (R)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal